Monthly Archives: December 2015

Today was my first day of OREX. I decided not to go to Grand Rounds this morning so I arrived at Highland Hospital around 11:00am. I was one of the individuals who did not go to the OREX orientation so today was definitely my trial-and-error day. Fortunately, the doctors, nurses, and scrub techs were very nice and helpful when I had questions throughout my day. I walked off the K5 elevators, went to the OR front desk, and got the vender card to get scrubs. Upon entering the women’s locker room, I saw the amazing, massive scrub-dispensing machine. I had never seen one before. The other hospitals I have been in as a nursing student had OR scrubs stacked on shelves. I guess that machine isn’t really supposed to be a highlight but I was intrigued that such a thing existed.

When arriving to the OR board dressed, I’ll admit I had a lost duckling kind of moment. I understood OREX participants are to look at the OR board, pick a surgery to observe, and basically go find it but I didn’t know which one to pick and who to tell, if anyone, which I wanted to see. I knew I wanted a surgery that hadn’t started yet because I didn’t want my first observation to be me entering a surgery midway. However the OR board didn’t have times listed so I had no idea what was happening when. Since I arrived around 11:00 and the OR had be up and running since ~08:30, surgeries were already in session. I asked Julie from the front desk which one I could observe and she then asked me which one I wanted to. I said I’d be okay with any surgery that hadn’t started yet so she told me to go watch OR 7. I walked over to OR 7 to find the staff cleaning the room for the upcoming surgery so I went back to the OR board to wait. There, I asked one of the doctors who wasn’t rushing anywhere how to read the board and get an idea of which surgery is occurring.

A few minutes later, I went into the pre-op area to see the patient of OR 7. I introduced myself and got her, the surgeon’s, and the anesthesiologist’s permissions to observe. The patient was a 46-year-old female here for the excision of a lipoma on her forehead and had no comorbidities. The surgeon performing the procedure was Ben (Dr. Shimel but he introduced himself to me as Ben) and the anesthesiologist was Dr. O. Dr. Allen was another one of the surgeons on this case and his role was to guide Ben through the surgery. Dr. O and Bang, one of the OR nurses, wheeled the patient into OR 7 to prep. The patient was given IV acetaminophen for pain and propofol (general anesthetic) to put her to sleep before intubation. Dr. O prefers administering oxygen through a tube rather than a facemask during surgeries in general because of it being a more closed system. What puzzled me was why another nurse switched out with Bang and a CRNA switched out with Dr. O. Throughout the surgeries I saw today, the nurses and CRNA and anesthesiologist would swap multiple times and I didn’t know why. Note to self to ask the next time I go in for OREX. When the surgery started, I definitely had a hard time seeing since it was being done on a very small area of the patient’s forehead and everyone participating in the surgery was well over a foot taller than me. I carefully navigated to the other side of the room for a hopefully better view. The scrub tech Joe told me it was okay to come closer and use a stool almost next to Dr. Allen. I was worried I was too close but the other doctors told me I was fine. The view from there was exponentially better but I was still too short to see into the incision. What I learned was the initial incision through the skin was done horizontally and then the tissues fibers that ran vertically were carefully separated (rather than being cut through). The cauterizing tool was used with tiny strokes to minimize bleeding and detach the lipoma from the site. When suturing the site closed, I learned that it is intended for the wound edges to slightly bulge with the sutures, as opposed to being exactly approximated and flat, because the skin will contract/shorten as the edges heal. Ben and Dr. Allen were also not worried about the slight concave characteristic of the incision site because fluid will eventually fill in the space where the lipoma used to be. The overall procedure took about 1.5 hours. The patient was wheeled to the PACU and report was handed off to the next nurse.

Since I was not following a particular resident, I hung around Ben until he left to grab lunch before his next case. I then found scrub tech Joe to see when OR 7’s next case was but he told me to go watch Dr. Krosin’s surgery because it was probably among the more awesome ones of the afternoon. I had seen it on the board earlier but didn’t want to enter since it had already started. I was reassured it’d be okay so Joe brought me to OR 5. Dr. Krosin and his team had been working on this case since about 10:00. It was a middle-aged male who was hit by a car while riding his motorcycle and then got his leg run over by another car. He was getting a ORIF of his L calcaneus. When I entered, Dr. Krosin and his physician assistant Megan were in the process of closing up the wounds. It seemed like they were almost finished but closing up took about 1.5-2 hours. There were multiple lacerations on the left leg that required suturing. Dr. Krosin spent a lot of the time closing up the heel; it was cut large and deep enough for him to fit in at least three fingers, and it was actively bleeding. When suturing the heel, Dr. Krosin sutured these cotton ball-looking pads to the heel to apply constant diffused pressure while the wound heals. Because of the heel’s structure and kind of tissue it contains, there would have been a risk of infection in the space inside the wound if only the wound’s edges were closed. Vancomycin powder was added inside the heel before closure as well to reduce the risk of infection. A Jackson-Pratt (JP) drain was added with the tube extending from the drain to deep inside the heel. JP drains look like plastic grenades and are meant to remove fluid building up in the wound. They are compressed to create a vacuum to suck out the fluid. Having fluid in the wound interferes with healing and may result in an infection. A Wound V.A.C. was then added for the lacerations on the leg. A Wound V.A.C. is a negative pressure wound treatment where suction is applied like a vacuum to the wound sites to enhance healing. Black foam is applied to the wounds and sealed completely by transparent tape. A hole is cut in the tape to apply the attachment to the suction machine. You know it’s working when the black foam is flat when the suction is on.

Today started out bumpy but now I know how to make my subsequent OREX days go by smoother.

I woke up at 5am with some anxiety. I stretched, dressed in my outfit, laid out the night before, and considered breakfast. I generally am not an eater of breakfast, unless I’m running a road race that morning, but I am a follower-of-directions. I reasoned that standing for several hours was not unlike a marathon. Peanut butter toast in stomach and coffee in hand, I headed out the door at 5:30. Bus, BART, Shuttle and I was in the conference room just before the first resident at 6:42.

Today’s discussion was on colon cancer.The residents/med students went around the table and discussed what they had found surprising in their reading. Examples included:

A behaviour trait study that indicated higher levels of aggressive behavior are associated with a greater risk of colon cancer.

It is important to screen patients for colon cancer after treating diverticulitis – not because it increases their risk, but to confirm that the diverticulitis diagnosis was not a misdiagnosis of colon cancer.

Fiber reduces risk of colon cancer partially becauses it encourages quick passage of stool but also because it may absorb bile salts which contribute to colon cancer.

A med student was asked to draw a colon on the whiteboard as well as the main arteries that supply it. This ended up being very useful as I would be spending several hours that day viewing that region of a patient’s gut.

There was a quizzing discussion of:

Intraperitoneal/retroperitoneal that was a bit over my head. But thanks to this handy diagram, I realize they were being quizzed on where an organ or an artery was in reference to the peritoneum.

How to differentiate between the colon and the small bowel

houstra in the colon, microvilli in the small bowel and not the colon

3. Layers of the bowel wall:

Mucosa–>sub mucosa –>muscularis –>sub serosa –>serosa

staging of colon cancer based on lesion level, node level and metastasis

A discussion on what research has found to prevent or contribute to colon cancer followed and included:

I put away my notebook and intended to introduce myself to Dr Harkin, but I was seated next to Ingrid (a nurse practitioner that I know from Healthy Hearts) and he needed to talk with her. I sat down and waited a couple of minutes to see if he would come back and then decided it was best to head to the fifth floor. Before I exited, Dr Cushman who manages all the med students introduced himself and asked about me. I explained the OREX program and he jovially introduced me to Martha George who is the command center of the surgical program, as described by Dr Cushman. He then escorted me to the 5th floor and advised me to go into OR 4 or 5. I changed as quickly as I could, but when I got back to the board everyone was already in surgery and I was nervous to go in unescorted. I then panicked-emailed the three volunteers that had already had their first day and asked their advice on whether I should go in once a surgery had started – general consensus = NO (Thanks Carlos, Pooja and Jenn!).

I went to the family waiting room and had a chance to meet “Grandma L” whose grandson was scheduled for surgery that day. We talked about how she felt about his care (the best in the world) and frustrations of a long recovery from a car accident. She didn’t feel like she fully understood what was planned for today’s surgery, but she was glad he was having his care at Highland. I let her get back to napping and peered at the board to see if there had been any changes in the last 30 minutes.

I was spotted by a very helpful nurse, Nanny(sp?), who encouraged me into OR4 and introduced me to the circulator, Benny as well as the surgical team Dr Sadjadi, Dr Martens (5th year resident) as well as two 2nd years and a medical student. I was placed on top of a stool near the patient’s feet. Finally, having a chance to take in my surroundings I saw on the whiteboard that this was a distal gastrectomy, the patient was male in his early 60’s, they were about 45 minutes in, and HOLY LORD this man’s colon was out of his body! I did a quick scan of my own body to see if I felt ill, but no. I was steady and this experience is amazing! The team had already cut open the patient’s body from 3 inches below his belly button to sternum and they were placing retractors in to allow for a better view of the cavity. Based on their discussion I gathered that his partial gastrectomy was due to the patient’s cancerous giant ulcer (a medical term indicating that this ulcer was >3 cm), that they were removing a substantial section of the stomach, many lymph nodes and forming a new connection to the bowels. This was delicate work and the time flew by. I was allowed to go to the side of the patient for a close (but still safely distant view) several times. The surgeons were so generous. I was even allowed to participate in the quizzing that went on with the anaesthesiologist and as I got two answers right (thanks recent physio exam!), I was awarded an extra viewing opportunity from behind the curtain that allowed me to see the patient’s pancreas when the floppy colon and muscular, but now ragged stomach, were moved aside. Everything was actually very pretty: pulsating hues of lavender, soft pinks, crimson clots, and occasional bulges of rich, yellow fatty tissue. The caudal lobe of the liver was exactly the shade of “stone” I had been looking for in my wedding invitations – taupe/gray. Dr Martens allowed me to glove up and feel the portion of the stomach that had been removed. It was very cold already, the outside felt thick and ropey while the inside was soft until you reached the ulcer, which I agree with medical science was GIANT. It was very hard and angry looking. I was so elated and thankful for the entire experience. Watching the patient wake up after having seen his liver only a couple hours ago was humbling. I was also aware that although his surgery was over, this would be only the beginning of his treatment. Chemotherapy would be next- he had a hard road ahead of him. It was 12:30 and it felt like I had wiggled through a wormhole where time felt weirdly dense with experience yet sped up. I was hungry for my next OR.

The board only showed circles to indicate if a patient had been seen – no times were shown. I asked a nurse, who knew me at this point, and she suggested that OR 5 or 2 would be my best bet. By 13:13, my name was on the board and I was standing in position for a bilateral inguinal hernia. The patient was in his late 60’s and male. He had been suffering from abdominal pain from the hernia. This was a much shorter surgery performed by two residents, Dr Lee and Dr Huyler with Dr Cushman coming in to supervise, on occasion. Tytus the surgical tech was blasting 90’s hip hop jams, and it was a little surreal to watch mesh being placed with precision and care while Tytus gyrated to early Mariah Carey. I admired Dr Huylers beautiful suture work. Once they were done with one side, you could barely tell that there had been a 4 inch incision. Because of the comparatively small incision, I couldn’t see as much of this surgery, but this allowed me time to focus on the instruments and the way in which tools, needles, and pads are accounted for carefully by the team. I am curious about the cauterizing tool that is used. It allowed the surgeon to stop bleeds, cut minor tissue, but does not cut through the surgeon’s glove. Does it use microwaves? Once the fascia was closed, Dr Lee kindly allowed me to ask questions. I know very little about hernias, so I asked about risk factors (heavy lifting), non surgical treatments (very few, time until it gets worse). The patient was difficult to wake from anesthesia, but soon he was out of the room.

The next surgical tech informed me that the OR would have a quick turnaround for an appendectomy, so I stayed in the area and followed the next patient in. She was in her mid 40’s and spoke only spanish, so I didn’t have a chance to communicate with her. The anaesthesia tech (Christina) escorted me through her entire process, and I felt very lucky. She allowed me to visualize the rings of the trachea she used to direct her intubation. The patient’s ET-tube and eyes were taped, the drapes went up, and I had a great seat for the laparoscopic appendectomy. Dr Lee and Dr Huyser were again at the helm with Dr Cushman overseeing the operation. A large hole was made near the patient’s belly button. Once the camera was in, the abdomen was blown up with CO2 and they were able to visualize the placements of two smaller holes for instruments. There was pus in the abdomen which indicated that the appendix had already perforated. It took skillful maneuvering to isolate the appendix from the bowel and any important veins/arteries. The surgical team’s discussion indicated that the location of the perforation (at the base) made the operation more difficult. Within an hour the appendix was separated and placed in a baggie inside the cavity. Once all the instruments were out, the bag was neatly pulled through the central hole. Christina explained that once the fascia was closed she would begin the process of allowing the patient’s body to stimulate itself to breath (by allowing CO2 levels to rise). As the patient woke up from her surgery, I said my thanks to the surgical team and anesthesia team for an amazing day, I saw that it was 6:30PM and my legs were filled with lead.

On my way out the door I stopped by Grandma L’s couch in the family waiting room. She was still there 11 hours later waiting for her grandson. Her daughter was now there and had brought her dinner. They were worried but in good spirits. I felt overwhelmingly grateful for the dedication that the surgical team was showing this lovely family’s son/grandson and for the spirit of inclusiveness and education they had shown me today.

The morning started with Dr. Harkin discussing a theoretical patient coming into the ED, a 55 year old male, complaining of chest pain. The residents were then encouraged to suggest possible diagnoses for this man, and rate the importance of the diagnoses as well as rate “HBIWBIWMI” (How Bad It Would Be If We Missed It”- or a similar acronym). Myocardial infarction, GERD, and other diagnoses were suggested, with different rankings of how bad it would be if they didn’t diagnose the problem. Dr. Harken then passed along various X-Rays, EKGs and results of other tests to narrow down the diagnoses. Ultimately, the lecture was on diagnosing MIs versus Pulmonary Embolisms versus Venous Thromboembolisms and how different studies have shown what treatments reduce the recurrences of PE and VTE in patients. This was a pretty interesting lecture because I had a very vein heavy surgery day.

After the lecture, I introduced myself to Dr. Harkin, who was very welcoming and he paired me up with Dr. Jessica Williams, a fourth year resident. Dr. Williams was a wonderful guide. She took me to the OR,helped me get the scrubs card and showed me how to work the futuristic scrubs machine. I was going to shadow Dr. Williams and Dr. Harkin for their three scheduled surgeries in OR2.

The first surgery was for varicose vein removal. The patient was a 44 year old African American Male, who had multiple varicose veins in his lower left leg that had been causing him pain. Dr. Harken explained that tissue that is stretched causes pain. Distended veins caused pain the same way stretched urethras caused pain. Dr. Williams explained that varicose veins were also removed for cosmetic reasons, but insurance did not cover those surgeries. Dr. Williams and Dr. Harken removed 5 different veins from the patient’s calf. One was very large and wrapped around the back of the leg, this was one was more difficult to remove because of it’s placement. Two small veins that were very close to the surface, near the ankle were also removed. Dr. Williams explained that these shallow varicose veins could eventually cause ulceration as the veins continued to swell and irritate the tissue around them. After all of the veins were removed, the patient’s calf was stitched up with stitches that would dissolve on their own, and the leg was wrapped up with gauze and a stretchy bandage.

The second surgery I was able to observe was also varicose vein removal. This time, Dr. Harken told me I could scrub in! So Dr. Williams showed me how to wash my hands and explained how I could not even rest my arms on my body after my hands were washed, avoid contamination. I was then shown how to dry my hands and suit up in a gown with two sets of gloves, and NOT TOUCH ANYTHING that was not blue! I made a mistake the first time I was gloved and had to be gloved again by the scrub tech. Luckily everyone was very nice and other than some gentle ribbing, I was given a pass.

The second patient was a 59 year old Caucasian Female, who was a former IV drug user, who also had Hepatitis C. I was instructed to watch the CRNA (Certified Registered Nurse Anesthetist) intubate the patient. She administered some anesthesia and a muscle relaxant to help relax the trachea for intubation. She explained that our patient did not have any teeth, and this made it difficult for her to form a seal when administering the oxygen mask. This patient’s problem vein was also on the left leg, but on her thigh. The vein was very long and was marked in ink on her leg. Dr. Williams made an incision in the top of the thigh and after exploring the area, could not find the problem vein, so Dr. Harken suggested she start again from the bottom of the marked vein. She was able to find the problem vein with the second incision, and a long incision was made up the thigh almost to the initial entry point, and the vein was removed successfully. This patient bled a lot more than the first patient, and many blood vessels had to be tied off or “zapped” (cauterized) with an electrified scalpel that Dr. Harken kept calling the Zapper (I just found out it is called a Bovie). The patient was sewn up by both of the doctors and sent to the recovery room.

The final surgery I saw today was an Arteriovenous Fistula (AVF). The patient was a 47 year old African American Male, and the surgery was performed on his left upper arm. The doctors were creating a connection between a vein and an artery (a fistula) for the patient to be able to receive dialysis. He had a previous fistula near his left wrist which apparently no longer worked, so they needed to create a new one. The patient had a funny tattoo on his arm that was kind of rude and it was funny to see Dr. Harken’s reaction to it. This patient was hard to anesthetize and jerked around a lot during his surgery. His hand had to be held down during most of the surgery, and his head kept rolling towards his left arm. At a certain point in the surgery, Dr. Harken exclaimed that he was resting his elbow on the patient’s face! Dr. Williams found a large healthy vein in the inner left arm and tied off one end. It was interesting to see a healthy vein after seeing the twisted and distended varicose veins from my first two surgeries. The vein was stained with ink and flushed with saline solution to stretch it out. There was a hole in the vein and some saline solution started spraying out at Dr. Harken, who quickly clamped the hole and instructed Dr. Williams on how to sew up the tiny hole with three small stitches. A second incision was made in the outer arm, parallel to the first, to locate an artery. Once a healthy artery was found, Dr. Harken traced on the skin where the vein would be brought across to connect with the artery. Dr. Williams used her scissors to cut away connective tissue underneath the skin and was able to pull the loose vein across to the artery. She then made an incision in the artery (which had already been clamped on both sides to prevent bleeding) and very painstakingly grafted the loose end of the vein to the incision in the artery. It was very delicate work with very small stitches. After the graft was complete, they irrigated the vein one more time to find any leaks in the stitches and performed a few final stitches to seal the leaks. At this point Dr. Harken sewed up the venous incision while Dr. Williams sewed up the arterial incision. You could see the fistula pumping arterial blood to the venous side already, it was slightly raised up in the skin.

Below is some information on an AVF that I found from the Davita website on hemodialysis:

A fistula used for hemodialysis is a direct connection of an artery to a vein. Once the fistula is created it’s a natural part of the body. Once the fistula properly matures, it provides an access with good blood flow that can last for decades. It can take weeks to months before the fistula is ready to be used for hemodialysis.

Fistula—the gold standard access

The National Kidney Foundation (NKF), Centers for Medicare and Medicaid Services (CMS) and Dialysis Patient Citizens (DPC) agree fistulas are the best type of vascular access.

A fistula is the “gold standard” because:

It has a lower risk of infection

It has a lower tendency to clot

It allows for greater blood flow and reduces treatment time

It stays functional longer than other access types

It’s usually less expensive to maintain

While the AV fistula is the preferred access, some people are unable to have a fistula. If the vascular system is greatly compromised, a fistula may not be attempted. Some of the drawbacks of fistulas are:

I recently moved and misplaced my journal with my notes from Dr. Harken’s lecture, so I’ll just jump into the surgery. I don’t remember the medical name for this case, (getting “ostomy” and “otomy” confused…) but this procedure was to replace a section of a man’s skull that had been removed and stored…in his thoracic tissue!

Before the surgery got underway, I met one of the neuro PAs, Larry. He was so nice and after introducing himself, pulled up the patient’s CT scan so I could see what happened. “You might see brain, today!” he mentioned, in his usual cheerful demeanor. The surgeon said that I wouldn’t see brain, just dura mater. Anyway, this patient had a stroke several weeks ago that resulted in swelling of the brain, readily evident on his scan. A section of his skull was removed (the size was a little bigger than a deck of cards) to allow the brain extra room as it healed. A sunken in area was readily visible on the patient’s head.

The skull section was stored in the patient’s side. I am not sure if it was in dermal tissue or further down, but it didn’t seem very far down. This was to keep the bone tissue viable while it was separated from its usual spot. The patient recovered for several weeks (I can’t remember how long but I remember marvelling that it was quite a long time to be without a portion of one’s skull, let alone have a portion of one’s skull in one’s side). What a crazy concept.

The first part of the surgery was to remove the skull fragment from its temporary pouch, which the surgeon did carefully but speedily. Then Larry stepped in to suture this opening up as the surgeon (I think his name was Dr. Patel) set about on the skull. The process of opening the man’s scalp was actually pretty interesting. After shaving his head around the existing scar from the first procedure (the scar wrapped from the forehead area around the ear and down to the back side of his head), Dr. Patel cut along the scar. He placed curved plastic clips around the borders of the skin flap on both sides as he went and I silently wondered what they were for. At this point, another PA came in to assist Dr. Patel as Larry had finished his suturing and left the OR to go round on patients.

Once the scalp was pulled back, Dr. Patel set about fitting little metal plates to help secure the skull fragment as it grew back. This was a careful, slow process. The rep from the company that makes these custom plates talked a little about the technology involved. Scans are taken of the patient and many different plates are made to give the surgeon multiple options. The screws can also be self tapping, meaning hollow on the inside so you don’t have to pre-drill a hole. I explained this to my husband later that day as a wildly amazing piece of information. His dad is a contractor and he was like, “Oh yeah, self tapping screws?” He seemed way less impressed. It’s kind of amazing how many similarities there are between ortho/osteo surgery and construction. Anyway, after the holes were drilled and the plates were on, it was time for bone cement!

Everyone took a minute to verify the directions. There was a powder and a liquid, and the scrub tech had to mix the solution for a certain number of seconds, and then Dr. Patel had a certain number of minutes to apply the paste until it set. He shellacked it on with great skill (obviously) and the paste filled in the areas that didn’t make a complete seal. I wasn’t able to ask this question, but the fit of the skull wasn’t 100% and I think it’s because the body probably harvested calcium from the bone edges during the weeks of healing. Again, that’s just my very uneducated guess….Anyway, the bone paste helped seal everything up and apparently also promotes bone healing.

The last phase was to close the skin up, and here’s where the plastic bits came into play. They served as markers to help the surgeon suture up the skin as accurately as possible. Something very important for any surgery, but especially where the face is concerned. No facelifts for our patient today. Also the suturing process was pretty bloody. After all, you can’t make any tourniquets around the head or neck area…and that concluded another special and informative day in the OR.

The first surgery I attended was performed by Dr. O’Shea, it was an ORIF of a tibia. The patient, fell out of his truck, and as a result broke his shin bone. He was already in a cast prior to the surgery, upon removal of the cast, I noticed that his leg was still very swollen. Later on in the surgery, I asked Dr. Krosin if the patient could heal well without the surgery. He replied that the patient definitely could, but this surgery speeds up the healing process and in fact, later after the surgery the patient would be walking!

The surgical preparation was unlike any of the other one’s I’ve seen before. The patient’s big toe was tied up with a white cloth, and this cloth was then later attached to what looked like an IV pole! It looked a little funny to see just his toe tied up so that his leg made a right triangle with the IV pole. I guess this way it would be easier to prep the patient’s entire leg from mid-thigh to in between his toes.

The surgery plan was to place a rod inside the tibia, that’s right, inside the tibia. Dr. Krosin explained to me that bones are hollow (for the most part), and with this surgery, they would be placing a rod inside the tibia. After that, Dr. O’Shea would then stabilize this rod with at least 4 screws to avoid torque when the patient walks. In essence, this rod would do a better job than a cast at stabilizing the broken bone and promote a faster healing process. The rod is made out of titanium, one of the metals that most human bodies don’t reject, so it will not have to be removed in the future! (but if he wants to, he can opt for another surgery to remove it, according to the x-ray tech, Analecia. I wonder what that surgery would look like!)

Surgery began with an incision above the knee, and from there, Dr. O’Shea went to work. Not only was it one of the most vigorous surgeries to watch, it used the scariest tools, and probably the most x-ray imaging. Keep in mind that in this surgery, only a few incisions were made, and everything that Dr. O’Shea was doing was very dependent on the x-ray technician. As a matter of fact, if we were take it back to a time without the technology of x-ray, we can say that Dr. O’Shea performed this surgery blindly. Basically, every centimeter in which he pushed the rod into the tibia, a picture was taken to see precisely where it was, and based solely on that picture, Dr. O’Shea was able to place a rod directly into the center of the patient’s tibia. I find it absolutely amazing what technology can do for the medical field.

The surgery lasted about 3 hours, I think that a majority of the time in the OR was spent taking x-rays to ensure that the rod would be placed in the proper alignment. Dr. O’Shea finished placing the rod in and took a little less time placing four screws into the patient’s leg. On a side note, Dr. Krosin also mentioned that it actually costs $200 per screw used in this surgery. So the amount of screws used really depends on both the surgeon and the cost!

After this surgery I attended a short procedure with Dr. MacDonald. I was invited in by the anesthetist, Dr. Reddy. This surgery called: laryngoscopy micro with excision of laryngeal mass. The patient came in complaining about hoarseness, and they found that he had a polyp growing on his vocal chords. Dr. MacDonald explained that the reason for hoarseness is because the polyp is heavy, and causes strain on the vocal cords. Before he began the procedure, he invited me to take a look at the patient’s throat through a microscope. The mass was hardly noticeable, and it looked like a small round fleshy part of the throat. Dr. MacDonald began the process of exposing the mass which took no more than five minutes. He then asked me to take another look through the microscope. This time the throat was bloody, and I could now see how large the mass actually was. Another ten minutes of surgical procedure and Dr. MacDonald finished! He removed the mass and placed it in a cup to be sent down to pathology and placed a piece of gauze to stop the bleeding. Once more, he allowed me to take a look through the microscope to see the finishing results.

This particular OREX day, I got to see two surgeries on both a micro and a macro level. That’s the beauty of surgery, whether big or small, this aspect of medicine makes a huge difference in a person’s life. Today it was inserting titanium into someone so he could hurry up and get back on his feet (literally) and for the other person it was removing a small piece of flesh so that they could speak with their own voice again.

Ill begin with the immortal words of the ninja turtles, “Radical Dude!”

Radical Abdominal Trachelectomy to be exact… with a hint of bilateral pelvic lymph node dissection, and a sprinkling of cerclage hysterectomy to boot!

In layman’s terms, I saw a forty year-old female patient with cervical cancer get her cervix removed and it was as intense an operation as it sounds. The bottom of the uterus was to be sewn to the vagina in hopes that the patient could still have a child. Basically, the cervix is nothing more than a passageway for sperm before fertilization, a conduit uniting vagina and uterus, and that purpose will now be carried out by the stretched bottom tissue of the uterus itself! Yes I realize I am finishing every paragraph with an exclamation point! (!)

After the 7AM discussion with the residents and a massive omelet off the HCP grill I walked into this already underway surgery and it was probably the crudest operation I have seen yet from an aesthetic perspective. The entire abdominal cavity was cut wide open; just a big gut-hole around 2.5 feet in diameter. The hole was kept open wide using a radial metal frame with 5 metal clamps pulling the skin and guts outward and away from the deep-set reproductive organs. I could make out the thick edges of the rectus abdominus, and internal oblique which had been separated to access the abdominal cavity. The stomach and intestines where pushed upward and held in place by the clamps and a wall of gauze towels. !

Once I had successfully geared up mentally for this surgery I actually began to take notes on the procedural steps being carried out. One doctor was holding onto the uterus at all times via four surgical clamps in order to give the other doctors access to the surrounding areas. They first worked to dissect the bladder from the uterine wall using the usual technique of cut+cauterize. Next, they took out the entire left and right pelvic lymph nodes in case they were infected with cancerous cells as well. The nodes were positioned right on top of the iliac artery and psoas muscles. Seeing all of this anatomy was so cool for me as I am a personal fitness trainer and I think about this “core musculature” all of the time. The other lymph nodes in the body can apparently compensate for the loss of the pelvic ones but there is a reported increase in swelling in 10% of the patients that undergo this surgery. The lymph node samples were sent down to the pathology lab to be screened for cancer.

The doctors put blue loops around both the L and R ureter because these vessels bring urine from the kidney to the bladder. It is REALLY important not to cut those bad boys on accident! They similarly ID’ed the obterate nerve… again, Watch Out! The doctors were finally able to fully separate the bladder from the uterus and there was a bit o’ vein severing along the way. I had a very informative discussion about blood vessels with all three surgeons and I was surprised to learn that while BP is higher in arteries than veins, veins will bleed more if cut. In this case, blood was actually spurting out of a uterine vein and it had to be clipped with a surgical tool that sounded sort of like a staple gun when the trigger was pulled. The patient had to be given two units of blood to make up for the massive loss!

Next came a lot of cut+cauterize… the cervix was cut along the superior proximal line where it turns into uterus (radical trachelectomy) and the inferior line where it meets the vagina and the entire organ was excised and sent down to pathology. The doctors then stitched around the newly opened “mouth” of the uterus and they stuck a long tube (basically a catheter) into the hole. A syringe full of saline was then pumped into the tube in order to expand a little balloon implanted into the uterus at the other end. This was to make sure the uterine tract remained open for the rest of the surgery. The abdominal cavity was so bloody at this point that the surgeons had to pour an entire jug of water into it to irrigate/ clean it before working on the uterine/ vaginal junction. The surgery was 5 hours in at this point and it was time for me to check out as there was still and estimated 2 hours left in the operation. These surgeons really do have amazing posture/strength/bladders!